08100085 CITY OF CUPERTINO
BUILDINQ DIVISION PERNUT MS' OMT"m"OWNF.OItMA
BUILDING ADDRESS: PERMrr N0.
10220 STERLING BLVD CHUAN—MIN CHANG 08100085
OWNER'S NAME: PERMrr I55UE DATE
CHUAN—MIN CHANG 10220 STERLING BLVD 10/16/2008
FVNE: SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u G G LICENSED CON RACIOR'S DECLARATION
1 barely affirm that I am lionsed under provisions of CTupmr 9(mmmmcmg Job Description
shn Section 70lk0o1"Divimm 3oftho Business and Professions Code,and my license is TEMP POWER POLE
in full force and.Rut
License Clan Lfu.0 '
n=❑ Date Convenor
e 7W7W
ARCHITECTS DECLARATION
e < 1 underaund my plans mail ha used u Public records
JyU
�C r^ Licensed Professional
i3 OWNER-BUILDER DECLARATION
<E 1 hereby asuman that 1 am exempt from the ConOactars License Law for One
•20 fallowing mutat.(Suction 7031.5.Business and Pmfesoam Code:Any city or county
which requhas a permit to cmuuucL after.Improve,dcmniied,or minor any structure
�Z i prior W its issue=.Stan requires the applicant farsuch permit a fik asigned sukmcut
< that he is licensed pursuant W the pmviaonaafdx ConuosSua,License law(Chapter 9 Sq.Ft.Floor Area Valuation
Y~$ (mmmencingwith Section 7")of Division 3ofShe:BusixuShall Profe¢ims;Cade)or $400
Q that he u eaempa them.and the India far Ne allegul eaemptiom Any violation of
Semon 7031.5 by any applicants for a permit subject,the applicant W a civil penalty of y Number Occupancy
trot mom thin r.hundred dallus ISM 37524026ANN y Type
❑I,as ownerofthe property.army moployem with wagesuNeir mfu comprnation,
will do Ihcwodt and doeswcmm u notintended ser aRetod(onset(Sec.7004,Busmen
and PmGsdlons Cade:The Conuemen's License Law dors not apply W an owner of Required Inspections
pmpeny who Wildsorimpnews thereon,and whodossuch workhimselfor through hes
own employees,provided that such improvements are not inundW oraRered for We.If.
however,the building or improvement is said within one year o(comple mn.We owner.
builder MB haw the nmden of proving that he did net build or improve for purpose of
sale). .r
W1.as owner of the property,am exclusively convening with Demand mniumm s m
construct the project(Sec 7000,Insurance;and Professions Cade:)Tx Comeacmfs U.
cause law dos not apply W an owner of property who IsmIds or improm themmm,and
who convects for such pmjecu with a caenumto(s)licensed pursuant to the Contractor's
Baena law.
❑1 tae t der See .B&PC for Nu moan
Owner Date 10 /6 6
WORKERS Oh A ON CLARATION
kI hereby afiitm under penalty of perjury o of the follawing declandons:
haw and will mustau a Cerdriam ofconsent W self-insure fowartmescompen-
'on,a provided for by Section 3700 of the labor Code.for Ne perfannano of the
watt for which this permit is named.
1 haw and will maintais Workers Compensation Imumnce,as required by Smtioo
3700 ofdteLater,Code.fer use Performance ofthe work for which that permit u issued. '
My Workers Compenaatioo Insurance artier and Policy number sae:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ibis section need nothecomplemd lythe permit is foronc hundred dollen(SIM)
or[am)
1 certih that in the performance ser a work for which Nis perm U issued,l 1 not
employ any parson in any j !c� mbcrnma bjectmthe�'Gran atlon
laws of CaI fomin Dam n / ��/...iii///
Applicant
NOTICE TO APPLICANT:If.after making this Cenirtam of FaemP6 n.you should
become subject W the Worker's Compausado provision,of the talo('oda you most
.,z forthwith comply with such prevision or Nu permit Nall be dare eked.
'Z O CONSTRUCTION LENDING AGENCY
(-+ I hereby afrnm that than is a cousvuctian funding age or the perfores of
CL the wish for which dila permit n issod(Sec.3097,Civ.C.)
Q Lcnder's Name
Lender.Add.
U Q I certify that 1 lava read this application um sure that the above lot.atiun is
V. H cancer 1 agree W comply with til city and county eminences and sat¢laws misting W
0U Wilding consnscdan,and hereby mdatiw mpmsentauvns of this city W cnw upon site
0. ahme-mentioned property for inspanion purposes.
(We)agree W ssw,indemnify and keep harrnlc s the City of Cupertino atom,
tires Iiabilium,judgummaScom andexpenma which may in anyway risme agars rid Ciy
U Z ren comuquence of Ne granting of Nu permit 1
APPLICAN'r,114DERSIANDS AND WILL COMPL WITH ALL NON-POINT Issued by: Date C'
SOUR LAMONS.
� 11
Re-roofs
Sig o A lion tn'7 m Dam
HAlARDOUS MATERIALS DISa0 Type of Roof
Will dm applicant or future Wilding aaupant norm le haamons nomond
as defined by the Cuperdnm Municipal Code.Chapter 9.1 nil the Health and Safety
Code. E]Y.25532(.)7 19x All roofs shall be inspected prior to any roofing material being installed.
❑Ya
Will the applicant or future Wilding aampant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hxusdow air contaminants at de0nad by the Bay Area Air Quality Management all new materials for inspection.
cR
[:]Y.
u
I haw mad NehauNam mamrianrequitements under C-mpus6.95 of dm Cui(an
nu Halth&SafmyCode,S .M5W.25533am125534.1maacmandthmifNeldlding
dam non currently .unant.Nat it Is my mapona bilis,to tifY the acoupant or Nc
requirements uveact prior Wissuanceof, 'r or Signature of Applicant Date
Owner or.m oriacd agent Dam' All roof coverings to be Class';W'or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 37524026 . 00
DATE ISSUED. . . . . . . : 10/16/2008
RECEIPT # . . . . . . . . . : BS000006362
REFERENCE ID # . . . : 08100085
SITE ADDRESS . . . . . : 10220 STERLING BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHUAN-MIN CHANG
ADDRESS . . . . . . . . . . : 10220 STERLING BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CHUAN-MIN CHANG
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : CHUAN-MIN CHANG
ADDRESS . . . . . . . . . . : 10220 STERLING BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -- ----- ---------- ---------- -- --------- --- -
1BSEISMICR VALUATION 400 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 , 40 . 79 0 . 00
1ERT<200 UNITS 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
------ ---------- ---------- ----------
TOTAL PERMIT 122 . 87 0 . 00 122 . 87 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------- --- ----
CREDIT CARD 122 . 87 AMEX
---------------
TOTAL RECEIPT 122 . 87
VOICE IO DESCRIPTION VOICE ID DESCRIPTION
---------------- --------- --
402 TEMPORARY POWER
•
Community Development
E 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
*UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # -sloes. aa6 99�
GENERAL CONTRACTOR: jAAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
• 4�L� f�, I e2Z e56le
Owner/Contractor Signator Date
O9l o(Do2
CITY OF CUPERTINO
�Pa' TEMP POWER
• CUPEIlTIN0 PERMIT APPLICATION FORM
APN # Date:
Building Address:
/ daa? dTF2Li.V� d�✓b. trr
Owner's Name: Phone #:
el-/1,4,4r/-.rl1,V c ,a�l 1/L6, a L,7 6. °/ 36
Contractor: Phone #:
SSE /rJ ArRW w� . 2o6. 91196
Fax #:
Contact: Phone #:
Contractor License #:
Cupertino Business License #:
Job Description:
Residential Commercial ❑
Valuation (cost of project): Type of Construction: N/
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>1K Res. Temp Power>1K E 1REAP14
Amps
1 ERT<200 Res. Temp Power<200 E
Amps
IERT2001K Res. Temp Power 200-1K E
Amps
IEPERMITFE Electric Permit Issuance E
IELCPLNCK Electric Plan Check E
/ IBSEISMICR Seismic Residential B
ITRAVDOC Travel & Documentation B
Fee
CITY OF CUPERTINO
TEMP POWER
CUPERTINO PERMIT APPLICATION FORM •
Quantity Fee ID Fee Description Fee Group Permit Type
1BSEISMICO Seismic Commercial B 10EAP14
IECT<200 Commercial Temp Power E
<200 Amps
IECT>IK Commercial Temp Power E
>1KAm s
1 ECT2001 K Commercial Temp Power E
100-1K Amps
ITRAVDOC Travel & Documentation B
Fee
1BUSLIC Business License B
Revised 6/16/08 •
•